Provider Demographics
NPI:1346420858
Name:ADVANCED SURGICAL SPECIALISTS OF NORTHEAST GEORGIA, LLC
Entity Type:Organization
Organization Name:ADVANCED SURGICAL SPECIALISTS OF NORTHEAST GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SOLE PROPRIETER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERMIE
Authorized Official - Middle Name:LENARD
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:678-413-2182
Mailing Address - Street 1:1359 MILSTEAD RD NE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3865
Mailing Address - Country:US
Mailing Address - Phone:678-413-2182
Mailing Address - Fax:678-413-2184
Practice Address - Street 1:1359 MILSTEAD RD NE
Practice Address - Street 2:SUITE 203
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3865
Practice Address - Country:US
Practice Address - Phone:678-413-2182
Practice Address - Fax:678-413-2184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033440174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000458092CMedicaid
GADE9275OtherMEDICARE RAILROAD GROUP
GAGRP7563Medicare PIN
GAE22107Medicare UPIN